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

We decided that the Plan does not have to pre-approve a power operated vehicle for the enrollee.

You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a home evaluation.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 vehicle. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the medical records received from the prescribing physician, there is no evidence of a personal mobility deficit that impairs participation in mobility-related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. There is no documentation that the mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. There is no documentation that the enrollee can safely operate the PMD. There is no documentation that the enrollee's home can accommodate the PMD. 

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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for headgear used with positive airway pressure device (A7035) tubing used with positive airway pressure device (A7037) filter, disposable, used with positive airway pressure device (A7038) provided October 13, 2020.

You asked the Plan to pay for the positive airway pressure device supplies. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says submit with required DME modifiers.

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 claim was submitted with KX modifier. The claim was not billed per Medicare guidelines DME fee schedule. Procedure codes A7035, A7037 and A7038 should be billed with NU modifier. Based on this information, we decided that Medicare rules for coverage of the positive airway pressure device supplies have not been met. Therefore, we decided that the Plan does not have to pay for headgear used with positive airway pressure device (A7035) tubing used with positive airway pressure device (A7037) filter, disposable, used with positive airway pressure device (A7038) provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210).

You asked the Plan to pre-approve a comprehensive oral evaluation and extraction. You say that you were referred to this provider by your dentist and it should be covered. The Plan denied your request. The Plan says they will only provide coverage for these services when they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.

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 a comprehensive oral evaluation and extraction only if the service is performed by a participating general dentist. 

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 and extraction have not been met. Specifically, the request is for services to be provided by an oral surgeon. The Plan covers a comprehensive oral evaluation and extraction only if the service is performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered reasonable or necessary at this time.

The Plan must follow Medicare rules. The rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 

The requested stimulator is not one that is covered by Medicare. 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 pre-approve an auricular stimulator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62324 provided on November 9, 2020.

You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, these services were billed with modifiers 59 and RT. Modifiers LT or RT are inappropriate for this procedure code. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 62324 provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair with multiple power options.

You asked the Plan to pre-approve the Group 3 Power Wheelchair with multiple power options.. You say that you would like reconsideration because the member needs the power tilt, recline and leg rests to meet their medical, functional and mobility needs throughout the day. The Plan denied your request. The Plan says the notes do not show that the member is able to safely operate the wheelchair or that the member's caregiver cannot use the manual wheelchair.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 Group 3 Power Wheelchair with multiple power options. Our reviewer says that the documentation does not support that the member can safely use the requested device. Our physician reviewer found the member is unable to perform any ADLs independently and requires maximal assistance with transfers using a mechanical lift and two person assistance. For these reasons, the documentation does not support that the requested wheelchair will safely and significantly improve the member's ability to perform MRADLs in the home. 

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 Group 3 Power Wheelchair with multiple power options. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 25, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the code billed.

The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 26, 2020 to September 24, 2020.

You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 26, 2020 to September 24, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the spinal canal.

You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this service
is medically necessary. The Plan denied your request. The Plan says that the member does not meet coverage
criteria.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the
requested MRI is medically reasonable and necessary. Our physician reviewer found further evaluation through
the use of advanced imaging would be appropriate given the member's symptoms/complaints and indeterminate
findings on prior examination.

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
MRI of the spinal canal.

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 a superior cervical ganglion block.

You asked the Plan to pre-approve a superior cervical ganglion block. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the proposed injection has not been shown to reliably impact member outcome for headaches.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a superior cervical ganglion block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational. 

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 superior cervical ganglion block have not been met. Therefore, we decided that the Plan does not have to pre-approve a superior cervical ganglion block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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. Our physician reviewer found as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs. 

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and to pay for the periodontal maintenance provided on December 22, 2020 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation or pay for the periodontal maintenance. You say that you were not aware that this provider was OON. The Plan denied your request. The Plan says these services were rendered by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that periodontal maintenance is not covered.

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, periodontal maintenance is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for services received OON. The record also shows that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and to pay for the periodontal maintenance provided on December 22, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.

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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services.

You asked the Plan to pre-approve lab services. You say that the tests are for a clinical trial. The Plan denied your request. The Plan says the cost of lab work associated with a clinical trial would be covered by Original Medicare.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve lab services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve lab services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on November 10, 2020, and December 8, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

The file shows that presumptive drug testing (CPT 80307) was provided with a diagnosis of opioid use, unspecified with unspecified opioid-induced disorder (F11.99). We looked at the file and the rules. The testing services are not covered for the diagnosis listed.

The file shows that definitive drug testing was provided. We looked at the file and the rules. The records show that 12 definitive testing services were provided prior to the dates of service at issue. It is not appropriate to report more than twelve definitive testing services per calendar year for chronic opioid therapy. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on November 10, 2020, and December 8, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for surgical pathology services (CPT 88307) provided to the enrollee on
October 14, 2020.

You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your
request. The Plan says that the diagnosis is for polyp of the stomach, but the service does not include anything
in the stomach.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found in this case, the diagnosis code is for gastric or duodenal polyp, K31.7. The pathology report describes a
hyperplastic gastric polyp. The report is consistent with the diagnosis and reflects medically reasonable and
necessary 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 services have been met. Therefore, we decided that the Plan has to pay for
surgical pathology services (CPT 88307) provided to the enrollee on October 14, 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.