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

We decided that the Plan does not have to pay for needle electromyography studies (51785) provided on January 30, 2019.
You asked the Plan to pay for needle electromyography studies. You say that this was medically necessary. The Plan denied your request. The Plan says this code is not supported by the records.
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 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique. 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 needle electromyography studies. Our reviewer says that CPT 51785 is not supported by the record. Our physician reviewer found the medical records provided do not include documentation of needle electromyography studies (EMG) of anal or urethral sphincter, any technique, therefore the service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography studies have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography studies (51785) provided on January 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 22, 2019.
You asked the Plan to pay for the laboratory services. You say that it is the responsibility of the patient and the patient's primary care provider to obtain any necessary authorization. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 and the referring physician in this case are not network providers with the Plan. 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 laboratory services provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient admission. You say that you cannot take care of yourself, and need physical therapy. The Plan denied your request. The Plan says that you have no new illness or injury that requires hospital care.
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. 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 an inpatient admission. Our physician reviewer found that you presented to the medical center on December 31, 2019, with suicidal ideation. You reported a recent stroke, which caused you to become a paraplegic. You expressed depression and anger with thoughts of killing yourself. You also have multiple medical problems, including heart disease, kidney failure, and diabetes. Therapy notes indicated that you were not able to care for yourself because of weakness in your arms and legs secondary to the stroke. The review has determined that on presentation to the medical center, the record showed that there was a reasonable expectation that your necessary hospital care would span two 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 an inpatient admission have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine injection provided on August 13, 2019.
You asked the Plan to waive the copayment for the spine injection. You say that you were told all you would have to pay is the copayment. You say that you cannot afford to pay. The Plan denied your request. The Plan says the copayment applied correctly.
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 $295 for all other ambulatory surgical center services. You have been asked to pay $269.23, which is less than the standard $295 copayment for the spine injection. The spine injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayment for the spine injection provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic genicular nerve blocks (64450) provided on March 21, 2019.
You asked the Plan to pay for the diagnostic genicular nerve blocks. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records do not support this service.
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 diagnostic genicular nerve blocks. 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 experimental/investigational and subject to multiple ongoing trials. 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 diagnostic genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic genicular nerve blocks (64450) provided on March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided on October 10, 2019.
You asked the Plan to waive the coinsurance for injections. You say that you have not had to pay for this procedure before. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The allowed amount is $514.75. The total amount you are being asked to pay is $102.95 ($514.75 x 20% = $102.95). Injections 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 coinsurance for injections provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion device.
You asked the Plan to pre-approve a continuous passive motion device. You say that CPM machines are used to try to maximize motion following shoulder arthroscopy and rotator cuff repair. The Plan denied your request. The Plan says CPM devices are only covered after knee replacements.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine sulfate solution for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this drug is not covered under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Morphine sulfate solution for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99053) provided to the enrollee on September 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for CPT 99053. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99053) provided to the enrollee on September 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stretta procedure.
You asked the Plan to pre-approve a Stretta procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Stretta procedure. Our reviewer says that the requested Stretta procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that available data in the enrollee's case supports that her gastroesophageal reflux is neither advanced, nor medically refractory. Of concern, the enrollee has symptomatic dysmotility with dysphagia which constitutes a relative contraindication to the proposed procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Stretta procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Stretta procedure.
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 believe that care in the IRF would be best for your recovery. The Plan denied your request. The Plan says you have no acute medical issues which require an IRF level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee is a male who was brought to the ED after multiple falls at home. He was found to have multiple fractures and a UTI. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 24, 2019 through July 30, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You submitted your bill for review. You say that you are appealing the charge. The Plan denied your request. The Plan says the copayment applied correctly.
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 $300 copayment per day for days 1-6. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day.
You have been asked to pay a $1,800 copayment per for the inpatient stay. ($300/day x 6 days = $1,800). The inpatient stay falls within the "Inpatient hospital care" 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 copayment for the inpatient stay provided from July 24, 2019 through July 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging (91110).
You asked the Plan to pre-approve the gastrointestinal tract imaging. You say that this service is medically necessary because regular endoscopy cannot reach the area to pinpoint the exact location of the small bowel obstruction. The Plan denied your request. The Plan says the member does not meet criteria for coverage of this service.
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 gastrointestinal tract imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is of uncertain benefit, and raises concern for potential adverse outcome. Available records do not address whether the requested capsule study is in prelude to bowel resection or what treatment will be offered to you when/if the capsule becomes impacted and completely obstructing. 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 gastrointestinal tract imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging (91110).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bariatric surgery.
You asked the Plan to pre-approve bariatric surgery. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and (3) been unsuccessful with medical treatment for obesity. 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 bariatric surgery. Our reviewer says that the requested bariatric surgery is medically reasonable and necessary. Our physician reviewer found that the enrollee meets all CMS criteria for bariatric surgery. The enrollee is an adult with a BMI that is greater than 35 kg/m2, it is 52 kg/m2. The enrollee has more than one obesity co-morbid condition, including pre-diabetes, PCOS, asthma and joint pain. The enrollee has failed physician supervised weight loss efforts. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bariatric surgery have been met. Therefore, we decided that the Plan has to pre-approve bariatric surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the physician 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 neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network specialists available to you that can provide the services you are requesting.
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 the physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants, porcelain crowns (D2740) for teeth # 8 and 9, and prefabricated post and core in addition to a crown (D2954) for teeth # 8 and 9.
You asked the Plan to pre-approve gingival irrigation, crowns, and prefabricated post and core in addition to a crown. You say that The Plan denied your request. The Plan says gingival irrigation, crowns, and prefabricated post and core in addition to a crown are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants, porcelain crowns (D2740) for teeth # 8 and 9, and prefabricated post and core in addition to a crown (D2954) for teeth # 8 and 9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care. You asked the Plan to pre-approve continued inpatient mental health care. You say that this is medically necessary. The Plan denied your request. The Plan says inpatient care is no longer needed. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 
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 continued inpatient mental health care. Our reviewer says that continued inpatient care is not medically necessary. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time beyond the plan-approved dates of service as he was not showing any dangerousness to self or others, auditory or visual hallucinations, or abnormal behaviors including aggression. This patient has been compliant with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions, hallucinations, or abnormal behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (CPT D5225).
You asked the Plan to pre-approve the immediate mandibular partial denture. You say that the enrollee has existing crowns on 5 and 13 with open margins and marginal leakage. You say that the enrollee has food traps around the gumline. You say that the enrollee complains of sensitivity on teeth. You say that coverage for dentures should be reconsidered to replace missing teeth 2-4 and to restore function and occlusion. You say that the enrollee is unable to eat on the right side due to missing teeth and due to experiencing supraeruption of mandibular teeth. The Plan denied your request. The Plan says immediate partial dentures are not a covered benefit under your contract.
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. While your appeal does mention the use of a maxillary partial type of denture (CPT D5211) we do not show that a prior authorization request was made for this service, nor was a determination for coverage made for this CPT code. Our decision is regarding the plan's denial of CPT code D5225. Though the Plan offers a dental benefit in excess of Medicare coverage, immediate partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an immediate mandibular partial denture (CPT D5225).