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

We decided that the Plan does not have to pre-approve an additional 9 months use of the semi-electric hospital bed.
You asked the Plan to pre-approve an additional 9 months use of the semi-electric hospital bed. You say that you have medial issues and no mobility, and this bed is medically necessary. The Plan denied your request. The Plan says you were approved for 3 months of the semi-electric hospital bed usage to transition from a hospital discharge, but the records do not show a need for the bed any longer.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. There are no records in the case file of a recent physician office visit and exam showing that the semi-electric hospital bed is still medically necessary. Based on this information, we decided that Medicare rules for coverage of an additional 9 months use of the semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 9 months use of the semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) and a porcelain/ceramic retainer crown (D6740).
You asked the Plan to pre-approve the pontic and retainer crown. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) and a porcelain/ceramic retainer crown (D6740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not 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 surgical repair of a hip fracture after a fall. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DaTscan (78830).

You asked the Plan to pre-approve a DaTscan (78830). You say that the requested DaTscan (78830) is
medically necessary. The Plan denied your request. The Plan says the requested DaTscan (78830) 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 DaTscan (78830). Our reviewer says
that the requested DaTscan (78830) is not medically necessary. Our physician reviewer found the member has
previously been given a diagnosis of Parkinson's Disease (PD), but he is said not to have had a clinical
response to a trial of a levodopa-based medication. The ordering provider seeks to differentiate between PD
and a Parkinson's Plus syndrome. While there is evidence in the literature to support the use of DaT-SPECT
(the requested service) in differentiating PD from essential tremor (and it is noted that the member has not
shown a tremor); such literature does not yet exist for differentiating between Parkinson's Disease and
Parkinson's Plus syndromes. In this context, it cannot be readily determined that the requested service is
consistent with the generally accepted standards of practice or care. The use of this test would be of
indeterminate clinical utility. In as much it would not meet the Medicare definition of medical necessity.

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 DaTscan (78830) have not been met. Therefore, we decided that the Plan does
not have to pre-approve a DaTscan (78830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve InterDry moisture-wicking fabric skin barrier.

You asked the Plan to pre-approve skin barrier. You say that you need this material. The Plan denied your request. The Plan says the denial of authorization for this supply is correct, because InterDry does not meet the definition of a dressing and is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that skin sealants and barriers such as InterDry are not covered because they do not meet the statutory definition of a dressing. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin barrier have not been met. Therefore, we decided that the Plan does not have to pre-approve InterDry moisture-wicking fabric skin barrier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on September 22, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) 99152 remains not supported.

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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sediation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." 

We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the operative note does not include documentation of a independent trained observer to confirm that all criteria included in CPT 99152 has been confirmed. The documentation does not include enough documentation to confirm an independent trained observer was present during procedure. 

We looked at this coder's review, the file, and Medicare rules. 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 moderate sedation services (CPT 99152) provided to the enrollee on September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76700) provided on May 13, 2020.

You asked the Plan to pay for an ultrasound. You say that this was performed twice. The Plan denied your request. The Plan says this exceeds MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 76700 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76700) provided on May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 thoracic compression fractures after a fall. Medical problems 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery back for portable oxygen concentrator (E1356).

You asked the Plan to pre-approve an extra battery back. You say that you need an extra battery. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have battery for your oxygen concentrator. This battery that you already have serves the same purpose as an extra battery back. Even though an extra battery might be helpful, it is not eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve an extra battery back for portable oxygen concentrator (E1356).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and cleaning (D1110) provided on September 3, 2020.

You asked the Plan to pay for the dental services. You say that you called the plan to find an in network dentist. You say that you were advised the provider in this case was in network. You say that you were not told that the dentist was no longer in network. You also say that you are on a limited income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says there is no record of a phone call prior to the date of service to verify benefits and provider eligibility.

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 oral exam (D0120) and cleaning (D1110) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve esophagogastroduodenoscopy (EGD) 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 that there have been no known changes since the last examination.

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 pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found fatty liver has emerged as a major risk factor in America for end-stage liver disese (e.g. cirrhosis). There is documented presence of portal hypertension in the setting of an enlarged fatty liver associated with elevated LFT's (in the absence of non-hepatic causes of portal hypertension) supports sufficient clinical concern for cirrhosis to warrant as medically necessary the repeat EGD as requested. 

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 pre-approve esophagogastroduodenoscopy (EGD) for the enrollee.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this denial is appropriate given the clinical scenario.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 26, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 76770 and 82270 are not supported.

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 76770 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete. The definition of code 82270 is blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection). 

We find that CPT codes 76770 and 82270 are not supported in the medical record. Specifically, there is no documentation of a complete real time retroperitoneal ultrasound with image documentation to support code 76770. There is no documentation of qualitative occult blood testing by fecal specimen to support code 82270. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L2-L5 decompression and fusion for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the provider's assessment notes do not indicate evidence of radicular pain.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no spinal instability or severe compression of the nerve roots on imaging studies. There is no recent trial and failure of 6-12 weeks of physical therapy. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L2-L5 decompression and fusion for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve facial feminization surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that there is no documentation showing facial features are impacting diagnosis or mental health.

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 pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The enrollee has gender dysphoria who was assigned male gender at birth but now identifies as female. The enrollee socially transitioned to female 10-years ago and has been on estrogen therapy on and off for 10 years. The enrollee is requesting facial feminization surgery to appear more feminine. The World Professional Association of Transgender Health Standard of Care document indicates that the requested procedure may be much more medically necessary than for somebody without gender dysphoria. In this case, the enrollee has transitioned to life as a female. A mental health professional has indicated that the requested procedure is one that will address depression, anxiety and self-esteem issue by addressing the gender dysphoria. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve facial feminization surgery for the enrollee.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 6, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was filed untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until September 16, 2020. The Waiver of Liability was not received until January 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the testing services rendered on June 6, 2019.