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

We decided that the Plan does not have to pre-approvePosterior Tibial Neurostimulation (64566).You asked the Plan to pre-approvePosterior Tibial Neurostimulation. You say that this procedure is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 Posterior Tibial Neurostimulation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Posterior Tibial Neurostimulation has been shown to be helpful for symptoms of bladder dysfunction in patients who are refractory to other therapies. It has not been demonstrated that the enrollee in this case is refractory to other therapies. The record shows the enrollee was using Myrbetriq with good results.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Posterior Tibial Neurostimulation have not been met.Therefore, we decided that the Plan does not have to pre-approvePosterior Tibial Neurostimulation (64566).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and provide records to support the services billed. 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided do not include sufficient information to validate that procedure 99153 was performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for physician services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram with video (95716) provided on
August 5, 2020, through August 7, 2020.
You asked the Plan to pay for the electroencephalogram with video. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95716 is electroencephalogram with video (VEEG),
review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous,
real-time monitoring and maintenance.
We asked our coder 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 electroencephalogram with video. Our reviewer says that
CPT code 95716 does not meet criteria for billing or reimbursement consideration. Our reviewer found the
medical records provided indicates that continuous Long-Term EEG was performed for a duration of 72 hours
and 39 minutes. This does not meet the coding definition of CPT 97156, therefore it is inappropriate to use
97156 to report the service provided.
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 electroencephalogram with video have not been met. Therefore, we decided
that the Plan does not have to pay for the electroencephalogram with video (95716) provided on August 5,
2020, through August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFoundation One Heme.You asked the Plan to pre-approvethe genetic testing panel. You say that you would like reconsideration because this testing is medically necessary.The Plan denied your request. The Plan says there is no documentation of a suspicion or diagnosis of acute myelogenous leukemia, myelodysplastic syndrome, or a myeloproliferative neoplasm.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 genetic testing panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have a covered indication for the requested testing.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 genetic testing panel have not been met.Therefore, we decided that the Plan does not have to pre-approveFoundation One Heme.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing
care needs include oxygen supplementation, tracheostomy care, neurologic checks, surveillance laboratory
studies, tube feedings, and therapy services.
The documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTranscranial Magnetic Stimulation Treatment.You asked the Plan to pre-approveTranscranial Magnetic Stimulation Treatment. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says prior episodes indicate the member has had multiple episodes of psychotic process.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 Transcranial Magnetic Stimulation Treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the member does not carry a diagnosis of major depressive disorder and has not undergone a course of evidence-based psychotherapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Transcranial Magnetic Stimulation Treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveTranscranial Magnetic Stimulation Treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 2, 2020.You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the provider is out-of-network and there is no authorization on file.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve
a removal of torus mandibularis (D7473).

You asked the Plan to pre-approve
the removal of torus mandibularis. You say that you need this service so that you can be fitted for bottom parcels.The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 removal of torus mandibularis (D7473).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health skilled nursing visits. You say that the requested home health
skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the requested home
health skilled nursing visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 home health skilled nursing visits. Our
reviewer says that the requested home health skilled nursing visits are not medically necessary. Our physician
reviewer found based on the documentation provided, the enrollee has been receiving home health skilled
nursing services to monitor and dress a chronic calf wound. The documentation indicates that the wound is no
longer measurable, 100% epithelialized and scabbed over. The enrollee lives with a younger family member,
who is willing and able to help. As such, the documentation does not support that ongoing home skilled
nursing services are medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora Tempus xT gene panel (81445) provided on October 10, 2019.You asked the Plan to pay fora Tempus xT gene panel. You say that this is a supported test.The Plan denied your request. The Plan says this is not covered.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 81445 is not supported in the medical record. Specifically, the record shows that this is CGP testing, which should be reported with 81749. Based on this information, we decided that Medicare rules for coverage of a Tempus xT gene panel have not been met.Therefore, we decided that the Plan does not have to pay fora Tempus xT gene panel (81445) provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient office visit provided on July 15, 2020.You asked the Plan to pay for the outpatient office visit. The Plan denied your request. The Plan says the provider is out-of-network and no authorization is on file.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 did not pre-approve the services at issue. We found no exception that would require the Plan to payfor these services. Therefore, we decided that the Plan does not have to pay for an outpatient office visit provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids (V5253, V5299, V5267) provided February 11, 2020.You asked the Plan to pay forthe hearing aids. You say that you preferred this provider from past experience.The Plan denied your request. The Plan says the provider is not contracted with the plan to provide hearing services, and therefore, the services are not covered.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained through the plan-contractedvendor.We looked at the file and the Plan's rules. These hearing services were not obtained through the plan-contracted vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forhearing aids (V5253, V5299, V5267) provided February 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran emergency room visit (99283, 86328) provided on July 11, 2020.You asked the Plan to pay foran emergency room visit. You say that this is supported by the medical records.The Plan denied your request. The Plan says the provider of this service is not enrolled in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules.The provider of the services at issue is not enrolled in the Medicare program.Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met.Therefore, we decided that the Plan does not have to pay foran emergency room visit (99283, 86328) provided on July 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDupixent.You asked the Plan to pre-approveDupixent. You say that you would like the Plan to reconsider their denial.The Plandenied your request. The Plan says Dupixent is not covered under the enrollee's Medicare Part B benefit.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-approveDupixent.Benefits for Dupixentmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services (D0999) provided July 28, 2020.You asked the Plan to pay forthe dental services. You say that the services should be covered.The Plan denied your request. The Plan says the code billed is not listed as a service that is covered under your dental plan.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 fordental services (D0999) provided July 28, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe outpatient surgical services rendered on June 22, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the claim was not billed with a CPT code.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claim was not billed with a CPT code; however, the file contains the claim form on which CPT code 43659 was billed for the date of service at issue. The Plan has not provided any documentation or Medicare rules to support that the claim is not payable as billed.Therefore, we decided that the Plan has to pay forthe outpatient surgical services rendered on June 22, 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
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the routine venipuncture (36415) and the laboratory services (80048, 85027) provided on July 29, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the routine venipuncture (36415) and the laboratory services (80048, 85027) provided on July 29, 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on February 1, 2018.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because you just received the member's insurance plan information. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the date when the services were rendered.
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 the ambulance services was not filed until October 12, 2020. 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 ambulance services (A0429 and A0425) provided on February 1, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient diagnostic radiology services provided on July 20, 2020.You asked the Plan to pay for the outpatient diagnosticradiology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider withthe Plan. The Plandid not pre-approve the servicesat 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 outpatient diagnostic radiology services provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fluoride treatment you received on September 30, 2020.You asked the Plan to pay forthe fluoride. The Plan denied your request. The Plan says this is not a covered 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 services are not among those covered under this benefit.  The Plan covers only those dental services listed in the Evidence of Coverage. Fluoride treatment is not covered.Therefore, we decided that the Plan does not have to pay forthe fluoride treatment you received on September 30, 2020