Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 11, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that this service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 36 months.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on January 20, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided on November 5, 2020.
You asked the Plan to pay for orthotic items. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because this supplier is not enrolled in or certified with Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for items or services, a provider or supplier must be enrolled in the Medicare program.
We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is therefore not payable. Based on this information, we decided that Medicare rules for coverage of orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for orthotic items provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint
nerve(s).
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with
imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and Destruction by
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or
sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636).
. You say that you have severe chronic back pain. The Plan denied your request. The Plan says bilateral MBBs
were not done at the L3-L4 level
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 destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet
joint (64635) and Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for
primary procedure) (64636).
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the record indicates that although two diagnostic blocks were ordered at
L3-L4, only one block at this level was performed in March 2021. The elements of the coverage rule are not
satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and Destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional
facet joint (List separately in addition to code for primary procedure) (64636) have not been met. Therefore, we
decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint
nerve(s).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (CPT code J0897), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says there is no indication the enrollee has had an osteoporosis-related fracture. The Plan states the enrollee has not tried and failed zoledronic acid and there is no indication zoledronic acid, an intravenous (IV) bisphosphonate drug, would likely be: less effective, and/or cause adverse effects for the enrollee.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 medication. Our physician reviewer found the Plan requires ONE of the following to be met: EITHER, a history of osteoporosis-related fracture; OR, the enrollee has failed, or has a contraindication to zoledronic acid (our preferred step therapy drug) before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (CPT code J0897), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on December 11, 2020, and December 12, 2020.
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the billed code.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include documentation of the time spent on critical care services. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on December 11, 2020, and December 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified occupational therapist,
direct skilled nursing services of a RN, and hospice or home health care provided from December 10, 2020, to
December 23, 2020.
You asked the Plan to pay for the services performed by a qualified occupational therapist, direct skilled
nursing services of a RN, and hospice or home health care. You say that you would like this claim to be
reprocessed for payment. 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. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on December 2, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services
performed by a qualified occupational therapist, direct skilled nursing services of a RN, and hospice or home
health care provided from December 10, 2020, to December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for excision, excessive skin and subcutaneous tissue abdomen, excision, excessive skin and subcutaneous tissue (includes lipectomy); arm, excision, excessive skin and subcutaneous tissue (includes lipectomy); other area, and Mastopexy provided on December 22, 2020.

You asked the Plan to pay for excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830), and excision, excessive skin and subcutaneous tissue (includes lipectomy); arm (15836), Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839), and Mastopexy (19316). You say that the procedures were medically necessary and not cosmetic. The Plan denied your request. The Plan says reconstructive surgery for cosmetic purposes is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.

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 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830), and excision, excessive skin and subcutaneous tissue (includes lipectomy); arm (15836), Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839), and Mastopexy (19316). Our reviewer says that the procedures were not medically reasonable or necessary. Our reviewer found the provided records include a single pre-operative visit that summarizes prior treatment without supporting documentation. The examination states the pannus "hung over the waistband." The examination states the skin was dry and that no rash present. No photographs were submitted for review. The submitted records do not support the medical necessity or reasonableness of the requested service as defined by Medicare rules. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830), and excision, excessive skin and subcutaneous tissue (includes lipectomy); arm (15836), Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839), and Mastopexy (19316) have not been met. Therefore, we decided that the Plan does not have to pay for excision, excessive skin and subcutaneous tissue abdomen, excision, excessive skin and subcutaneous tissue (includes lipectomy); arm, excision, excessive skin and subcutaneous tissue (includes lipectomy); other area, and Mastopexy provided on December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 28, 2020.
You asked the Plan to pay for the ambulance services. You say that you were extremely ill, had been exposed
Covid and did not want to put others at risk for the coronavirus. The Plan denied your request. The Plan says
these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 28, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 28,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on February 22, 2021.
You asked the Plan to pay for the home visit. You say that the treatment received was medically necessary and the physician provided a statement of medical necessity. You say that the claim should be processed for payment. The Plan denied your request. The Plan says services were not ordered or performed by an in-network provider and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 home visit provided by an out-of-network provider on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing services provided on January 7, 2021.

You asked the Plan to pay for the services provided. You say that the testing was needed to know what medical issue is going on so that proper treatment can be given. The Plan denied your request. The Plan says the service is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. In this case, there are insufficient medical records to show that the testing was ordered to assist in a specific treatment strategy. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the Covid-19 testing services provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 13 and 14.
You asked the Plan to pre-approve the crowns. You say that the enrollee needs these crowns to be approved for coverage. The Plan denied your request. The Plan says a tooth must be present to have a crown placed on it. The Plan also says that the x-rays clearly show there are no upper teeth remaining on this enrollee.
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 crowns 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 crowns. Our reviewer says that the documentation provided does not support the need for crowns for tooth #'s 13 and 14. Our physician reviewer found the enrollee's dental record and radiograph indicate the absence of tooth #'s 13 and 14 for which crown restorations were prescribed. 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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 13 and 14.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for an elective left arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) (CPT code 23472).
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 27447 is not listed on the CMS Inpatient Only List. The Plan states there is no documentation provided to support the expectation that you 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 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 payment are met in this
case. Our physician reviewer found the health plan's denial of pre-authorization for inpatient level care should
be upheld. You are to undergo a procedure that is not on the inpatient-only list and is not shown to be expected
to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities,
which are expected to necessitate a prolonged (i.e. two midnight) stay. You should present for, undergo and be
monitored following the procedure as an outpatient. Should complications arise, which necessitate a prolonged
(i.e. two midnight stay) than you can be converted to inpatient status under the two-midnight rule.
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 an elective left arthroplasty,
glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) (CPT code
23472).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on September 8, 2020.You asked the Plan to pay for drug testing. You say that this is supported in the records.The Plan denied your request. The Plan says this was billed with an incorrect POS.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator placement.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) and implantable neurostimulator electrode, each (L8680). You say that the enrollee has severe back pain. The Plan denied your request. The Plan says the enrollee failed psychological clearance for the requested spinal cord stimulator.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The psychological evaluation determined the enrollee does not appear to be an appropriate candidate. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural (63650) and implantable neurostimulator electrode, each (L8680) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulator placement.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lumbar decompression.
You asked the Plan to pre-approve percutaneous lumbar decompression. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 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 percutaneous lumbar decompression. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that percutaneous lumbar decompression is experimental. More research is needed to show safety and efficacy of the procedure. Open laminectomy is the gold standard. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lumbar decompression.