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

We decided that the Plan does not have to pre-approvea continuation of skilled nursing facility (SNF) services.You asked the Plan to pre-approvethe continuation of SNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says continued care can be provided in an alternate setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 indenying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee completed a course of IV antibiotics. Her lungs were clear and her appetite was fair. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a maximal assist with dependent level for functional mobility. The enrollee remained non-ambulatory and required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning July 14, 2020. You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that continued stay is only custodial in nature. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary in this case. It is not expected that you would improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. 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 as you do not have dangerousness to self or others and are compliant with your treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. Our physician reviewer found that your condition does not meet Medicare criteria for continued inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning July 14, 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 non-coverage of IRF care will jeopardize the
enrollee's chances for a full recovery. The Plan denied your request. The Plan says the request does not meet
the criteria for coverage.
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 ongoing pain medication and other medication management, wound care, and daily
therapy can be provided at a SNF. The enrollee is mostly maximum to total assist for functional transfers and
activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear
the enrollee would be able to fully benefit from and/or participate in an IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two anterior retreatments of previous root canal therapies (D3346 x2) and retreatment of previous root canal therapy of a molar (D3348).
You asked the Plan to pre-approve the retreatments of previous root canal therapies. You say that the submitted documentation supports a favorable decision. You also say that tooth #31 has an unfavorable prognosis for additional endodontic therapy. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 two anterior retreatments of previous root canal therapies (D3346 x2) and retreatment of previous root canal therapy of a molar (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist services provided on March 24, 2020.You asked the Plan to pay forthe perfusionist. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for the service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules.The facility must furnish all necessary covered services tothe beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay forthe perfusionist services provided on March 24, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on February 20, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided to the enrollee on February 13, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for stomach cancer.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 the various denied codes are not supported in the medical record. Specifically, this test must be coded with 81479 instead of the separate CPT codes. 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 forGuardant360 testing provided to the enrollee on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4mg Pomalyst capsules.
You asked the Plan to pre-approve Pomalyst. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's condition under Medicare Part B.
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 4mg Pomalyst capsules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #25.
You asked the Plan to pre-approve the extraction. You say that the enrollee needs tooth #25 extracted. You also say that extraction (D7210) is the only code covered under this enrollee's plan, no lesser code is covered. The Plan denied your request. The Plan says the documentation does not support that surgical techniques are necessary for tooth removal.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the extraction when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the extraction. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation presented does not appear to support the need for a surgical extraction of tooth #25. Our reviewer also found that a routine extraction (D7140) appears appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 3, 2020.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger 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 separately payable.
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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient for these services. Payment for this service would be included in the part A DRG payment to the facility. Payment for this service would be the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foracupuncture services.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, it appears that your pain is originally due to a surgery.Therefore, we decided that the Plandoes not haveto pay foracupuncture services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for skin graft substitute billed for services provided on December 7, 2019.You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the documentation did not indicate the exact date the services were performed.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 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.We find that CPT code 15275 is not supported in the medical record. The documentation does not show the skin graft substitute was provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for skin graft substitute billed for services provided on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on January 7, 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 the services are not covered.
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 64492 is 1. You billed 2 units of this code, exceeding the MUE. 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 injection services rendered on January 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received dialysis, and has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a moderate to maximal assist level with bed mobility, and dependent for transfers. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on November 14, 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 procedure code 27093 is 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 27093 is injection procedure for hip arthrography; without anesthesia.We find that CPT code 27093 is not supported in the medical record. Specifically, the records show that arthrocentesis was performed and there is a more appropriate code for these services. 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 injection services rendered on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a power seat elevation feature for reach and support to carry on daily health, hygiene and mobility.The Plan denied your request. The Plan says Medicare does not consider this feature to be primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 19, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you went to the dentist with the understanding it was a normal extraction. You also say that when you got there, they said it was not. The Plan denied your request. The Plan says this service 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, the requested items or services are not among those covered under this benefit. The Plan contract clearly states that only routine oral exams and comprehensive oral exams are covered by your Plan. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided to the enrollee on March 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 pay for the services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not documented as part of a maintenance program.
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 not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided to the enrollee on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (PCR amplification Reflex molecular UTI tests) provided to the enrollee on March 26, 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 experimental or investigational services are not covered.
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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the records do not provide any justification as to why a standard urinalysis with culture and sensitivities would not be appropriate for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (PCR amplification Reflex molecular UTI tests) provided to the enrollee on March 26, 2020.