Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical removal of an erupted tooth (D7210) and periodontal scaling (D4341).
You asked the Plan to pre-approve the tooth removal and periodontal scaling. You say that the member has significant plaque buildup and needs a surgical extraction due to breakage on a non-restorable tooth. The Plan denied your request. The Plan says the x-rays do not show the need for bone removal or sectioning of the tooth.
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 tooth removal and periodontal scaling 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 tooth removal and periodontal scaling. Our reviewer says that plan criteria requires that for scaling and root planing there be notable bone loss around the affected teeth or root surface calculus. In this instance there is noted bone loss around tooth #1, but the supplied panoramic x-ray does not show clear bone loss around other teeth in that quadrant or root surface calculus. Given the reported pocket readings along with the panoramic x-ray, code D4341 which is reserved for four or more teeth per quadrant would not be an appropriate code. A lesser code would appear to be appropriate for this situation as there are less than four affected teeth as seen on radiograph. Our physician reviewer found the request for surgical removal of tooth #13 was made. It is premature to request a surgical removal which requires cutting of bone, and if there is need during the procedure. 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 tooth removal and periodontal scaling have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical removal of an erupted tooth (D7210) and periodontal scaling (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UPWalker upright mobility walker.
You asked the Plan to pre-approve an UPWalker upright mobility walker. You say that your hips and back ache due to hunching over your current walker. The Plan denied your request. The Plan says you are expected to recover from the hip procedure.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules say that additional expenses for "deluxe" equipment or features, or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. The file shows that you have a four-wheeled walker with seat. The four-wheeled walker with seat serves the same purpose as an UPWalker upright mobility walker. Your assessment shows an upright walker is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve an UPWalker upright mobility walker.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 2, 2019.
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 the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
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 80307 and HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on April 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute 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 requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee presented to the hospital on 2/20/20 for left leg weakness. Her MRI of the brain was negative for acute stroke. Her MRI of the spine reveals bulging disc and nerve compression at L3/4. She has a history of lumbar spinal stenosis for which she received an epidural injection on 2/25/2020. She also has a history of lumbago, hypertension, chronic kidney disease and shingles. On 2/26/20 the enrollee needed maximum assistance for bed mobility rolling, moderate assistance for sit to supine, moderate assistance for sit to stand, and supervision for dynamic standing. She declined gait training. In occupational therapy (OT) she was sit to stand x 5 at bedside with maximum assistance for safety. Per a medical progress report on 2/26/20 the enrollee has a history of chronic cerebral vascular accident on aspirin. Her ataxia is being worked up by neurology. For pain management she is using multimodal pain regimen including opioids for her low back pain and left lower extremity paresthesias. She has anemia which may be leading to early fatigue in therapy. Hypertension is being monitored. Her renal insufficiency and hyponatremia are being monitored. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and OT but the enrollee does not appear to have the functional tolerance to tolerate this therapy on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered prepared meal (S5170).
You asked the Plan to pre-approve home delivered prepared meal. You say that the enrollee is a diabetic with declining health and is not able to cook at home and requires assistance with meals. The Plan denied your request. The Plan says the records do not show that you had recent acute or subacute hospitalizations, therefore, nutritional meals are not covered.
The Plan must follow Medicare rules. Medicare does not cover home delivered prepared meals. But the plan has a benefit that exceeds Medicare. The Plan contract says that meal benefits is covered after a discharge from an acute inpatient hospital stay or skilled nursing facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home delivered prepared meal have not been met. Therefore, we decided that the Plan does not have to pre-approve home delivered prepared meal (S5170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the shoe extension was requested to rectify your leg length discrepancy that is a result of your hip surgery. You stated that the request is due to the unacceptable outcome of your hip replacement surgery that is causing you spine and leg pain. You say this is the first step in rectifying the outcome of the surgery and the Plan should cover it. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 26, 2019.
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 the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
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 80307 and HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 4, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says panoramic x-rays are covered once every 3 years. The Plan also says that the frequency limit has been exceeded.
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 and panoramic x-rays are a covered service, the frequency limit has been exceeded. The records shows that you last received a panoramic x-ray on August 6, 2019 which the Plan paid for. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis provided on May 2, 2019 by an out of network provider.You asked the Plan to pay forthe wrist hand finger orthosis (L3807). You say that prior authorization is not required for DME.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the itemat issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay forthe wrist hand finger orthosis provided on May 2, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 11, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation indicates that Train of Four Testing/Monitoring was performed which does not meet the CMS guidelines of CPT code 95999
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, train of four monitoring does not meet CMS guidelines of CPT code 95999. Additionally, payment for train of four monitoring is bundled with the payment for the primary neuromonitoring procedure. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your legs are in very bad shape and you cannot walk well. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 9, 2019.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 Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory 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 care that cannot be provided by network providers.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. 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 physician services provided to the enrollee on September 9, 2019.
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 services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for aspiration pneumonia. The enrollee was intubated/ventilated upon presentation, but has since been extubated and is no longer on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 31, 2019 and billed under code 21012 with Place of Service (POS) code 11.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says based on the Medicare billing guidelines, code 21012 cannot be billed with POS code 11. The Plan states that this was not the most appropriate service performed for the place of service 11. The Plan states that a corrected claim would be reviewed if submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POS code. In this case the POS reflected on the claim cannot be billed with code 21012 and cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on October 31, 2019 and billed under code 21012 with Place of Service (POS) code 11.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity 1.5/0.5 Inj.You asked the Plan to pre-approveTrulicity 1.5/0.5 Inj. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveTrulicity 1.5/0.5 Inj.Benefits for Trulicity1.5/0.5 Injmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNFcare provided to the enrollee from June 15, 2019 through July 14, 2019.You asked the Plan to pay forSNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member continued to receive wound care. She had pain interfering with function which needed to be assessed and treated. Her hospital course had been complicated by metabolic encephalopathy and delirium which were complicating factors in terms of managing her pain.There were no identified ongoing skilled therapy needs. Based on the member's progress to date the expectation of achieving gains that would impact the burden of care at discharge with skilled services was not expected. Skilled services as of the date in question were not medically necessary or reasonable. There were skilled needs, but they did not need to be provided on a daily basis. The member was receiving care that couldhave been provided by her non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The member's condition would not be expected to have deteriorated with services provided on a less than daily basis. The member'scare could have been provided at a custodial level with intermittent skilled 
services on a less than daily basis.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 care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from June 15, 2019 through July 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSightPsychotropic test provided on September 24, 2019.You asked the Plan to pay for the GeneSightPsychotropic test. You say that the test was medically necessary and is a Medicare-covered test.The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 and the referring physician in this case are not network providers with the Plan. The Plan did not pre-approve the GeneSight Psychotropic test. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on September 24,2019