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

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs these supplies for his
post surgical recovery. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M) provided on November 4, 2020, by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like the claim reprocessed. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 genetic testing (0012M) provided on November 4, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a paravertebral injection (64493) and interlaminar injection (62323) provided on March 8, 2021, to April 5, 2021.

You asked the Plan to waive the co-payment for each injection. You say that you should not have to pay the cost share for outpatient surgery. You also say that in the past, you have paid an office visit cost share instead. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for each outpatient diagnostic test and therapeutic services and supplies.

You have been asked to pay a $50 co-payment for each injection. The records show that you had these injections in an outpatient facility, performed in an operating room. The EOC confirms that $50 is the required co-payment for each service. The injections fall within the outpatient diagnostic tests and therapeutic services and supplies 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 co-payment for a paravertebral injection (64493) and interlaminar injection (62323) provided on March 8, 2021, to April 5, 2021.
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 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.
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. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories and features defined by codes (E2311), Expandable Controller (E2377), Expandable Controller Harness (E2313) and K0108 Q-Logic Controller K0108), Joystick Mount Adapter (K0108), Polyurethane Liner (K0108) & Seat Elevator (E2300).
You asked the Plan to pre-approve the wheelchair accessories. You say that the claim should be paid. The Plan denied your request. The Plan says they will overturn and approve the power wheelchair, but some the associated accessories associated are still denied.
The Plan must follow Medicare rules. Medicare rules say that the seat lift does not serve a primary medical purpose. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. The requested joystick module controller and joystick mount are still denied. This is part of the requested controller and cannot be requested separately. There is a request for covers for the seat and back cushions. These are already included with the requested cushions. They cannot be covered separately. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories and features defined by codes (E2311), Expandable Controller (E2377), Expandable Controller Harness (E2313) and K0108 Q-Logic Controller K0108), Joystick Mount Adapter (K0108), Polyurethane Liner (K0108) & Seat Elevator (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine with and without contrast (72158).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the enrollee was being treated for bilateral low back pain, unspecified chronicity, unspecified whether sciatica present. She is noted to have had six months history of low back pain with previous surgery. In the past six months, she has experienced significant progression of her low back pain. It is limiting her ability to move from a sitting to standing position. She can only ambulate with difficulty. She does admit to pain both in the buttock's region as well as the anterior thighs. She has decreased sensation in her feet (likely due to diabetes). However, detailed documentation is not evident regarding severe and/or progressive neurological abnormalities. Furthermore, there is documentation of previous surgeries to the lumbar spine; however, the dates and procedures performed were not specified. Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures.
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for an MRI of the lumbar spine with and without dye is not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine with and without contrast (72158).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on August
30, 2020.
You asked the Plan to pay for home health services. You say that a corrected RAP claim has been submitted
multiple times. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim at
issue is stated to be a RAP, but it was not billed with a type of bill that is valid for a RAP (0322 or 0328).
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee
on August 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 18, 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 code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and this code is not appropriate for those 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 testing services rendered on November 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the shoulder for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of chronic pain and/or persistent tendonitis.

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 requested MRI is not medically reasonable or necessary. Our physician reviewer found there is difficulty with adduction/abduction due to pain. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The provided findings do not support indication of any significant worsening and/or clinical progression. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for MRI of the left shoulder is not medically reasonable or 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the shoulder for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), the unspecified periodontal procedure, by report (D4999), and the gingival irrigation - per quadrant (D4921) received November 18, 2020.
You asked the Plan to pay for the dental services. You say that the requested services were pre-approved. The Plan denied your request. The Plan says the claim has been reprocessed, however the requested services (D1330, D4999, D4921) are not covered under your supplemental 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 pay for the oral hygiene instructions (D1330), the
unspecified periodontal procedure, by report (D4999), and the gingival irrigation - per quadrant (D4921)
received November 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on December 30, 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 95999 and 95955 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. The definition of code 95955 is electroencephalogram (EEG) during non intracranial surgery (eg, carotid surgery). 

We find that CPT codes 95999 and 95955 are not supported in the medical record. Specifically, there is no documentation of an unlisted neurological or neuromuscular procedure to support code 95999. The file shows that Train of Four testing was performed and 95955 is not the correct 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 testing services rendered on December 30, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Eylea. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for 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 pay for the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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 pay for long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional physical therapy visits.
You asked the Plan to pre-approve 9 additional physical therapy visits. You say that the enrollee requires continuous therapy. The Plan denied your request. The Plan says the enrollee is not able to improve with the requested services.
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 9 additional physical therapy visits. 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 based on the submitted medical records, the enrollee appears to have plateaued with therapy. She is wheelchair bound and requires assistants in her home to live independently. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic (D6245) for tooth #3 and retainer crowns (D6740) and core buildup procedures (D2950) for teeth #2, #4 and #5.
You asked the Plan to pre-approve the bridgework. You say that you and your dentist agree that these services are medically necessary, and you do not understand why they are being denied. The Plan denied your request. The Plan says that there is a poor long-term prognosis for the teeth in this quadrant due to periodontal disease and too little bone support. The teeth and restoration will not last long.
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 bridgework 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 bridgework. Our reviewer says that the criteria are met for a fixed bridge replacing tooth #3. Our physician reviewer found that your dental records and x-rays indicate that the abutment teeth have greater than 50% bone support. It is the opinion of our medical reviewer that the bone support of the abutment teeth is adequate for a good prognosis and the treatment is medically reasonable and necessary.
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 bridgework have been met. Therefore, we decided that the Plan has to pre-approve a pontic (D6245) for tooth #3 and retainer crowns (D6740) and core buildup procedures (D2950) for teeth #2, #4 and #5.
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.