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

We decided that the Plan does not have to pre-approve continuation of in-home maintenance services of a venous port catheter using alteplase.You asked the Plan to pre-approve the continued in-home port catheter maintenance. You say that the enrollee has the venous port catheter and these services are necessary to maintain it.The Plan denied your request. The Plan says without any need for IV drugs, or any reasonable expectation of the need for IV drugs, continued maintenance of this port is not required. Literature does not recommend keeping a venous port if not being used.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 continued in-home port catheter maintenance. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 59 year old female with a history of Crohn's disease, with "symptoms of bowel inflammation which improved significantly on Stelara." She had a venous port placed in 2015. She has maintained this venous port to this day with monthly nurse visits for maintainence to flush the catheter with alteplase. She is no longer receiving IV drugs but uses subcutaneous Stelara for her Crohn's. The Medication List includes medications administered orally, topically and by subcutaneousroute (Stelara), without any medication listed administered by IV or by infusion. No reasonable anticipation for the need for Port-a-cath utilization was documented in the recent previous GI documentation. The review has determined that the enrollee no longer receives IV drugs and has no need to maintain this venous port. As such, continued visits/ drugs to maintain the port are not medically necessary.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 continued in-home port catheter maintenance have not been met.Therefore, we decided that the Plan does not have to pre-approve continuation of in-home maintenance services of a venous port catheter using alteplase.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency
department only if the emergency clinic is affiliated with a hospital.
We looked at the file and Medicare rules. The facility in question is a freestanding emergency department that
is not affiliated with a hospital. Additionally, this provider is not enrolled in Medicare. This means that
payment cannot be made for the services in question. 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 provided on January 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin and Paclitaxel. You asked the Plan to pre-approve the requested drugs. You say that if the enrollee cannot participate in the clinical trial, the tumor may get bigger. The Plan denied your request. The Plan says Original Medicare covers routine costs associated with clinical trials. The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the requested drugs as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Carboplatin and Paclitaxel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #9 for the enrollee.
You asked the Plan to pre-approve a crown. You say that this is medically necessary. The Plan denied your
request. The Plan says that the tooth does not appear to have significant breakdown.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a crown 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 a crown. Our reviewer says that a
crown is not medically reasonable and necessary for the enrollee in this case. The provided radiograph shows a
missing area of tooth involved the DIFL aspect of #9, encompassing the incisal edge and about 25% of the
tooth. The Plan provides that "Permanent anterior teeth must have pathologic destruction to the tooth by caries
or trauma, and must involve four or more surfaces and at least 50% of the incisal edge." Although there is a
substantial amount of missing structure, it does not meet the stated requirements for crowns under the Plan. The
tooth may be restored with a conventional composite restoration. Our physician reviewer found that the
enrollee's condition does not meet criteria for the crown.
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 a crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2750) for tooth #9 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device (22869).
You asked the Plan to pre-approve the interspinous spacer device. You say that you would like reconsideration
because this device would provide significant clinical and quality of life benefits. The Plan denied your request.
The Plan says this device is experimental/investigational.
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 interspinous spacer device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the device remains experimental and more research is needed to show its
safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the interspinous spacer device have not been met. Therefore, we decided that
the Plan does not have to pre-approve an interspinous spacer device (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient physical therapy services for the enrollee.You asked the Plan to pre-approve the additional services. You say that this is medically necessary.The Plan denied your request. The Plan says additional visits are not required prior to the left knee total arthroplasty.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 pre-approve the additional services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has a chronic knee pain from OT and was approved for a TKA. He has made some progress in therapy but the records do not indicate he requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee has had extensive therapy and should be able to transition to a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.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 additional services have not been met.Therefore, we decided that the Plan does not have to pre-approve additional outpatient physical therapy services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (99239) provided to the enrollee on October 7, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the billed service, 99239, was denied because it did not include the appropriate primary, first-listed or principal diagnosis, per the ICD Manual. The Plan states that based on the ICD Manual, a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows that systemic inflammatory response syndrome (SIRS) was the reason for hospitalization, the presenting complaint was severe back pain. In the discharge note it even says that the elevated white blood cell count, which is why you diagnosed SIRS, may have been a response to the severe pain. The back pain is reported M54.9 but according to this coding convention, that should be reported as the primary as it is the underlying condition which caused the SIRS. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (99239) provided to the enrollee on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe aflibercept injection provided on February 26, 2020.You asked the Plan to waive the coinsurance forthe aflibercept injection. You say that you were informed you would have 0% coinsurance for Part B injections.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.You have been asked to pay $378.01, which is 20% of the allowed amount for the aflibercept injection. The allowed amount is $1,890.06 (20% x $1,890.06 = $378.01). The aflibercept injection falls 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 forthe aflibercept injection provided on February 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen supplies provided on July 8, 2019.
You asked the Plan to pay for the oxygen supplies (A0422). You say that the Plan should pay this claim. The
Plan denied your request. The Plan says supplemental oxygen is already included in payment for air ambulance
services.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
We looked at the file and Medicare rules. The cost of oxygen and its administration in connection with and as
part of the ambulance service is covered. Under the ambulance Fee Schedule, oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are NOT separately
payable. Based on this information, we decided that Medicare rules for coverage of the oxygen supplies
(A0422) have not been met. Therefore, we decided that the Plan does not have to pay for oxygen supplies
provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scaling and root planing-four or more teeth per quadrant (D4341) and the periodontal scaling and root planing-one to three teeth per quadrant (D4342 x 3) provided on March 3, 2020.You asked the Plan to pay forthese 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 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 services provided are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal scaling and root planing-four or more teeth per quadrant (D4341) and the periodontal scaling and root planing-one to three teeth per quadrant (D4342 x 3) provided on March 3, 2020.
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. The Plan denied your request. The Plan says the enrollee cannot
be expected to actively participate in intensive therapy.
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 physician reviewer found
that you were at maximum assist for lower body dressing, moderate assist for ambulation using a rolling
walker, contact guard assist for activities of daily living, and minimal assist for transfers, bed mobility, and
standing. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status currently does not
currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple
therapies, such as physical and occupational therapy, but the documentation does not support that you require
an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision exam and routine eye wear provided
March 2, 2020 by an out-of-network provider.
You asked the Plan to pay for the vision services. You say that you was told by the provider's representative
that they recently became participating with the plan. You was never told that they was a non-participating
provider for this benefit. The Plan denied your request. The Plan says enrollee's must receive their vision
services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when rendered by a participating provider.
We looked at the file and the Plan's rules. For covered vision benefits, services must be provided by an innetwork
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision
exam and routine eye wear provided March 2, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on September 9, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not appropriate reflect the services provided by the certified nursing assistant. 
 
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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the record indicates that the services were rendered by a certified nursing assistant, not a physician, physician's assistant or nurse practitioner. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99350) provided on September 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99348) provided on August 12, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not appropriately reflect the services provided by the certified nursing assistant.
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 99348 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99348 is not supported in the record. Specifically, this code is billing for the medical decision-making of a doctor and the record indicates that these services were rendered by a certified nursing assistant. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit (99348) provided on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148). You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria for the MRI has not been met. The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found there was no indication from the records that the enrollee had a red flag diagnosis which might warrant bypassing a first line treatment trial. Therefore, this request for lumbar MRI will be considered not medically necessary 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided on March 12, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided on March 12, 2020.