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

We decided that the Plan does not have to pre-approve continued SNF care.

You asked the Plan to pre-approve SNF care. You say that you should not be released from the SNF due to dementia and that a home setting is unsafe for you. The Plan denied your request. The Plan says your present needs are custodial in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing nor skilled therapy service needs. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.

You asked the Plan to pre-approve the mandibular partial denture. You say that you will be providing a scaling and debridement to clean below the gumline. You also say that you will be scheduling 6 month appointments as well. The Plan denied your request. The Plan says based on the records provided, the gums/bone around this tooth looks unhealthy.

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 mandibular partial denture 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 mandibular partial denture. Our reviewer says that the mandibular partial denture does not meet coverage criteria. Our physician reviewer found the remaining teeth are compromised periodontally. The provider had noted that there was scaling planned and regular six month follow up recalls to be scheduled. Our reviewer found that in the case of periodontal disease, scaling and root planing is usually followed up with more frequent cleanings using code D4910 due to the demands of treating the condition. Given the significant bone loss seen in the provided x-ray, a lower partial denture with cast metal frame cannot be found as necessary at this time. Our physician reviewer also found that a tissue borne appliance (all acrylic) may be an acceptable alternative as the occlusal forces are not borne significantly by the periodontally compromised teeth.

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 mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and preventive procedure provided on November 12, 2020.

You asked the Plan to pay for the prophylaxis and preventive procedure. You say that you would like these services to be covered. The Plan denied your request. The Plan says you had met your annual or lifetime maximum 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 Plan offers a $1,000 allowance for covered dental services. The contract says that you pay 100% of charges beyond the $1,000 allowance. The record shows that you met the annual maximum benefit on December 7, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis and preventive procedure provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the additional periapical x-ray (D0230) provided on October 2, 2020.

You asked the Plan to pay for the dental services. You say that your previous dental office was destroyed in a hurricane and destroyed your medical records. You say that you had to go to another dentist for an evaluation. You said that you had to have x-rays done since your previous ones had been lost due to the hurricane. You also say that you feel you should not have to pay for the x-rays. The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 plan years. The Plan says that 1 periapical x-ray is covered every calendar year. The Plan also says that the frequency limits for these services have 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 comprehensive oral evaluations and periapical x-rays are listed as covered services, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on February 27, 2020. The record also shows that the Plan paid for the initial periapical x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the additional periapical x-ray (D0230) provided on October 2, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy for breast cancer- Initial Phase: sixteen (16) fractions of IMRT, Boost Phase: four (4) fractions of electrons, IGRT for initial phase, (CPT code (s) 77336, 77412, 77427, and 77387), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than the type of treatment the Plan can approve.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is safe to say that IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose distribution in select patients when the dose-volume exposure of the heart and lungs warrant its use. For IMRT to be medically necessary, an appreciable benefit must be achieved. IMRT can be considered medically necessary when a clinically meaningful reduction in normal tissue dose exposure can be achieved. For this patient, the improvement in the IMRT vs. standard plan with respect to lung dose exposure is evident in the provided records. Our physician reviewer found that IMRT would be furnished in accordance with accepted standards and other LCD criteria are 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 the services have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy for breast cancer- Initial Phase: sixteen (16) fractions of IMRT, Boost Phase: four (4) fractions of electrons, IGRT for initial phase, (CPT code (s) 77336, 77412, 77427, and 77387), for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81235, 81270, 81272, 81275, 81310, 81311, 81314, 81321, 81404, 81405, and 81406) provided on August 14, 2020.

You asked the Plan to pay for Guardant360 testing. You say that this is Medicare-covered testing. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that Guardant360 is coded with CPT 81479. 

We find that CPT codes 81120, 81121, 81173, 81235, 81270, 81272, 81275, 81310, 81311, 81314, 81321, 81404, 81405, and 81406 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81235, 81270, 81272, 81275, 81310, 81311, 81314, 81321, 81404, 81405, and 81406) provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on October 27, 2020.

You asked the Plan to pay for the services provided. You say that the refraction was part of a routine eye exam. The Plan denied your request. The Plan says refraction is not payable separately.

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.

We looked at the file and the Plan's rules. The file shows that you received and were billed for a medical eye exam on the date of service at issue. Refraction services are only covered when they are provided with a routine eye exam. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor, for the enrollee.

You asked the Plan to pre-approve the item. You say that the sensor is necessary. The Plan denied your request. The Plan says the following prior authorization criteria has not been met: use with insulin three or more times per day, or use of an insulin pump, or has a history of hypoglycemia due to insulin use, and the prescriber attests that insulin dosing requires frequent adjustment.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the item. Our physician reviewer found we are not told that the enrollee uses insulin; hence the provided criteria are not met since they require MDi and adjustments in insulin dosing based on blood glucose level.

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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is 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 in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT, lower extremity; without contrast material (CPT code 73700) to be performed at an out-of-network provider.

You asked the Plan to pre-approve the CT scan. You say that you are requesting approval of the CT scan to proceed with upcoming surgery. The Plan denied your request. The Plan says review of the enrollee's medical information confirms that there are no exceptions for the enrollee to see an out-of-network provider. The Plan states there are network providers available within the enrollee's area.

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 pre-approve 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the CT, lower extremity; without contrast material (CPT code 73700) to be performed at an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667).

You asked the Plan to pre-approve the DME. You say that without this device you may not be walking in six (6) months due to the pain from Lymphedema. The Plan denied your request. The Plan says it does not appear that there is Lymphedema extending onto the chest, trunk and/or abdomen.

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 DME have not been met. Review of the records show that you have Lymphedema of lower extremities. The rules state that this device is not covered for Lymphedema of legs alone. Furthermore, E0667 is not covered unless criteria for E0652 are met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the crowns. We decided that the Plan does not have to pay for the crown for #4.

You asked the Plan to pay for the crowns. You say that this is medically necessary. The Plan says that the x-rays do not show teeth missing from a cavity, or a lot of damage from being broken.

We decided that the Plan has to pay for the crown on tooth #31.

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 dental services 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 for a crown on tooth #31. Our reviewer says that this crown is medically reasonable and necessary. Our physician reviewer found this tooth meets the criteria for coverage for a crown restoration due to a large restoration, recurrent caries and noted fracture lines on three surfaces. 

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 crowns have been met. Therefore, we decided that the Plan has to pay for the crowns on tooth #31.

We also decided that the Plan does not have to pay for the crown for #4.

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 dental services 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 for a crown on tooth #4. Our reviewer says that the requested crown is not medically reasonable or necessary. Our physician reviewer found that it is possible that the tooth indicated for the crown was meant to be #5. Tooth #4 does not exhibit compromised coronal structure to warrant a crown restoration. 

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 crown for #4 have not been met. Therefore, we decided that the Plan does not have to pay for the crown for #4.

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 Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from June 3, 2020, through November 2, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the member has an HMO Plan with no out-of-network coverage except for urgent/emergent services.

The Plan must follow Medicare rules. Medicare rules say that a Masters of Social Work is not eligible to participate in the Medicare program. 

We looked at the file and Medicare rules. The provider at issue in this case is a Masters of Social Work. Medicare says that a Masters of Social Work is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from June 3, 2020, through November 2, 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. You say that the stay is 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the care you received.

You asked the Plan to waive the deductible. The Plan denied your request. The Plan says your deductible was not met.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that you have to pay out-of-pocket before the Plan will pay its share for your covered medical services.

Review of the file shows that you were provided inpatient care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that you have to pay out-of-pocket before the Plan will pay its share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received. Therefore, we decided that the Plan does not have to waive the deductible for the care you received.