Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve the 16 additional skilled nursing home visits. 
 
You asked the Plan to pre-approve the additional home health services. You say that you have had wound care 
for over a year and the Plan keeps denying the request. You also say that your wounds get worse and you have 
to start again. The Plan denied your request. The Plan says that you already have a total of 33 skilled nursing 
home visits, including the partial approval of 9 out of 25 visits. The Plan also says that the records provided 
show that the approved visits should be sufficient to help you transition/educate you on your wound care from 
home skilled nursing visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. 
Our reviewer says that the services of a skilled nurse to evaluate, monitor, and tend to your wounds is 
medically necessary and reasonable. Our physician reviewer found you are noted to have multiple lower 
extremity diabetic wounds. A couple of these wounds have apparently healed, but several wounds remain and 
are to receive wound care thrice weekly. Our reviewer found that you are homebound and live alone. Our 
physician reviewer also found that the Plan has not shown a reduced need for services (that is order for twice 
weekly wound care), your ability to care for wounds yourself, caregiver availability to care for the wounds or a 
change in homebound status (that you are no longer homebound). 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 home health services have been met. Therefore, we decided that 
the Plan has to pre-approve the 16 additional skilled nursing home visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that you are benefiting from the PT and believe that you can continue to make progress with additional visits. The Plan denied your request. The Plan says the additional PT is 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 pre-approve ten (10) additional PT 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 that you have previously been treated with outpatient and inpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete lower denture.
You asked the Plan to pre-approve the complete lower denture. The Plan denied your request. The Plan says you are not currently eligible for an additional complete lower denture.
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, you also have a maximum benefit of one denture every 5 years. The Plan paid for the denture provided on October 16, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete lower denture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan.
You asked the Plan to pre-approve a FDG PET scan. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for the requested imaging service have not been met.
The Plan follows Medicare rules. Medicare rules say that enrollees must meet the diagnostic criteria for both AD and FTD before coverage can be approved for the requested FDG PET scan. 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 FDG PET scan. Our reviewer says that the requested FDG PET scan is not medically necessary and reasonable. Our physician reviewer found Patient has had symptoms of cognitive decline for greater than 6 months. Neurology referral is pending but hast not occured yet. In this case, there is a requirement of a possible diagnosis of FTD in addition to Alzheimer's disease to qualify for FDG-PET and there is no mention of such a diagnosis at this time. Therefore, the criteria for coverage have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a FDG PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services provided from December 21, 2020, to December 23, 2020.
You asked the Plan to pay for the services provided. You say that the doctor did not remove any polyps. The Plan denied your request. The Plan says the copay was 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 a $300 copay in an outpatient hospital facility for outpatient surgery.
The file shows that you received a colonoscopy after a positive Cologuard test. The colonoscopy is not considered a screening because of the positive test. You have been asked to pay a $300 copay in an outpatient hospital facility for the services provided. the services provided falls within the outpatient surgery 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 pay for the colonoscopy services provided from December 21, 2020, to December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance 
transport (A0428) provided on March 12, 2021. 
 
You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that the 
enrollee required ambulance transportation due to an altered mental status, left sided paralysis and history of 
breast cancer-causing additional weakness of extremities. The Plan denied your request. The Plan says 
ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare 
covered benefit. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ground mileage and non-emergency 
ambulance transport. Our reviewer says that the documentation does not support that the ambulance transport 
on March 12, 2021 was medically reasonable and necessary for the enrollee. Our physician reviewer found the 
documentation support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or 
other type of vehicle) were not contraindicated for this enrollee. Our reviewer also found that the 
documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance could provide for safe transport on March 12, 2021. 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 ground mileage and non-emergency ambulance transport have not been met. 
Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency 
ambulance transport (A0428) provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical stimulation device and supplies.
You asked the Plan to pre-approve an electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766). You say that this device is medically necessary. The Plan denied your request. The Plan says there is no evidence to support the use of this device for the enrollee's diagnosis.
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 an electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is denied as KPS=60(need to be 70), she was non-compliant with Optune as she could not tolerate, and she never received effective radiotherapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766) have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical stimulation device and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on April 19, 2021.

You asked the Plan to pay for incomplete endodontic therapy. You say that the service should be covered at 50%. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88305) provided October 20, 2020.

You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the number of units billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 2 units of CPT code 88305 are not supported in the medical record. The medical record only supports 1 units of CPT code 88305. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. The plan has already paid for the 1 covered unit. Therefore, we decided that the Plan does not have to pay for pathology services (88305) provided October 20, 2020.
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 enrollee needs LTACH services. The Plan denied your request. The Plan says the enrollee does not require a prolonged acute inpatient admission.

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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment (E0431, E0424, E1399) provided October 
26, 2020. 
 
You asked the Plan to pay for the oxygen equipment. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The claim was billed with place of service 11. This does not represent the patient's home. DME for use outside 
the home is non-covered. Therefore, we decided that the Plan does not have to pay for oxygen equipment 
(E0431, E0424, E1399) provided October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 80061, 84443, 85025) provided March
22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered for the diagnosis code billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The lab services were requested solely for screening purposes. The diagnosis code billed was Z0000, general adult medical exam with no abnormal findings. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (80053, 80061, 84443, 85025) provided March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided April 8, 2021.
You asked the Plan to pay for the fixed partial denture sectioning. You say that this service was necessary to extract a tooth and you would like the cost adjusted to be lower. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 fixed partial denture sectioning (D9120) provided April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (90999) provided November 3, 2020 to November 28, 2020.
You asked the Plan to pay for the dialysis services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a required modifier.
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 90999 is not supported in the medical record. Specifically, the required G modifier to note the most recent URR was not included on the claim. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services (90999) provided November 3, 2020 to November 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from after 9:30 a.m. on November 7, 2020, through November 10, 2020.

You asked the Plan to pay for inpatient hospital care. You say that the hospital services provided were medically necessary. The Plan denied your request. The Plan says the services at issue were not approved in compliance with the health plan's authorization procedures.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 inpatient hospital care. Our reviewer says that the enrollee was stable to transfer as of November 7, 2020 at 9:30 a.m. Our physician reviewer found all inpatient care provided after 9:30 a.m. on November 7, 2020, through November 10, 2020, was not needed on an emergent basis. The treating physician did not document that the enrollee was not stable for transfer. 

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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided after 9:30 a.m. on November 7, 2020, through November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography, sleep staging with 4 or more additional parameters of sleep, (95810).
You asked the Plan to pre-approve the polysomnography. You say that please review attached clinicals. Due to the enrollee's mental health issues, a home sleep test would not be ideal. The Plan denied your request. The Plan says the records do not support that the requested service is not medically necessary
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 polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee with a diagnosed sleep disorder, severe depression, anxiety, personality disorder, and insomnia. No symptoms suggestive of sleep apnea or narcolepsy or other approved indication for a sleep study was documented. The enrollee's sleep disorder is likely directly related to her psychological diagnoses and would not benefit from a sleep study. Therefore, this request for such does not meet LCD criteria. 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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography, sleep staging with 4 or more additional parameters of sleep, (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of residual tooth roots (D7250 x2) provided on March 19, 2021.

You asked the Plan to pay for removal of residual tooth roots. You say that you do not agree with the charges. The Plan denied your request. The Plan says the services at issue are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for removal of residual tooth roots (D7250 x2) provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an intraoral periapical radiographic image (D0220), and bitewing radiographic images (D0274) provided on January 11, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, a teeth cleaning, an intraoral periapical radiographic image, and bitewing radiographic images. You say that you thought the provider was in-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider. An intraoral periapical radiographic image is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, an intraoral periapical radiographic image, and bitewing radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Additionally, an intraoral periapical radiographic image is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an intraoral periapical radiographic image (D0220), and bitewing radiographic images (D0274) provided on January 11, 2021.