Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation provided on January 13, 2021.

You asked the Plan to waive the copayment for the psychiatric diagnostic evaluation. You say that the doctor did not do anything for you, and you are not crazy. You say that you do not think you should owe $25. The Plan denied your request. The Plan says the copayment 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 $25 for each individual or group therapy visit for Medicare-covered outpatient mental health services.

You have been asked to pay $25 for the psychiatric diagnostic evaluation. The psychiatric diagnostic evaluation falls within the "Outpatient mental health care" benefit category. The records show an evaluation was performed. 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 copayment for the psychiatric diagnostic evaluation provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia and subsequent hospital services rendered on November 25, 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 the submitted records do not support the billing of codes 99152 or 99233.
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 99152 is Moderate sedation services by physician requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. The definition of code 99233 is Level 3 subsequent hospital care for evaluation and management of patient, including detailed interval history and medical decision making of moderate complexity, typical time 35 minutes.
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 these services. Our reviewer says that the submitted records do not support the billing of codes 99152 or 99233. Our physician reviewer found the operative report does not document the presence of an independent trained observer required to report CPT 99152. The documentation submitted does not support the use of modifier 25. There is no documentation of subsequent hospital care with medical decision making of high complexity to support the billing of code 99233. We looked at this physician's review, the file, and Medicare rules. 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 anesthesia and subsequent hospital services rendered on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your request. The Plan says incisional biopsy of oral tissue is not listed as a covered service.
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 incisional biopsy of oral tissue is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the backup battery for CPAP (E1399).

You asked the Plan to pre-approve the battery backup battery. You say that please provide a battery backup for use with the CPAP due to frequent electrical interruptions at home that impair an effective use of the CPAP and need to avoid complications related to an untreated OSA. The Plan denied your request. The Plan says a battery backup does not meet the definition of DME and is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules for coverage of the battery backup battery have not been met. Therefore, we decided that the Plan does not have to pre-approve the backup battery for CPAP (E1399).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you are under hospice election.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The file shows that you are under the Medicare hospice benefit. The Plan cannot approve services while under the hospice benefit. The request should be submitted to Original Medicare. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee has a history of spinal stenosis with back pain and neurogenic claudication. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the shoulder.
You asked the Plan to pre-approve the MRI of the shoulder. You say that you would like reconsideration
because your physician says that you require this test to continue your treatment plans. The Plan denied your
request. The Plan says you have not had 6 weeks of provider-directed, conservative treatment of the shoulder.
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 of the shoulder. Our reviewer
says that the provided documentation is insufficient to establish the medical necessity and reasonableness, as
defined by Medicare rules, of the requested service. Our physician reviewer found the provided records do not
include a complete physical examination of the arm due to pain that persisted without motion. The enrollee has
worsened cervical spine pain.
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 of the shoulder have not been met. Therefore, we decided that the Plan
does not have to pre-approve MRI of the shoulder.
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 enrollee does not meet criteria for IRF admission. 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. The enrollee was admitted for craniotomy for resection of arteriovenous malformation (AVM). Medical conditions are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve BRCA 1&2 panels.
You asked the Plan to pre-approve the BRCA 1&2 panels. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that a similar test that checks if the member is at increased risk of developing breast and ovarian cancer was approved oreviously and a separate gremline BRCA is not needed at this time.
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 BRCA 1&2 panels. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the National Comprehensive Cancer Network Guidelines recommends BRCA testing in all women that have metastatic breast cancer and are HER2 negative such as this member. 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 BRCA 1&2 panels have been met. Therefore, we decided that the Plan has to pre-approve BRCA 1&2 panels.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5225) provided on January
14, 2021.
You asked the Plan to pay for the maxillary partial denture. You say that you were not notified about changes
with your insurance for the 2021 Plan year. The Plan denied your request. The Plan says this service is not
covered.
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
maxillary partial denture (D5225) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 99223, CPT 99238) provided to the enrollee from October 20, 2020 to October 21, 2020.
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 more than one discharge service was billed for the same date of service.
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 the denied codes is: CPT 99238: Hospital discharge day management; 30 min CPT 99223: initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key
components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the plan included documentation of a paid claim (#024789653400) for CPT 99223 and CPT 99238. Therefore, billing a second time for same dates of service and same procedure codes results in duplicate billing, and therefore would not be covered. We looked at this coder's review, the file, and Medicare rules. 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 physician services (CPT 99223, CPT 99238) provided to the enrollee from October 20, 2020 to October 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of chest with contrast (71260) and a CT scan of abdomen and pelvis with contrast (74177).
You asked the Plan to pre-approve a CT scan of chest with contrast (71260) and CT scan of abdomen and pelvis with contrast (74177). You say that the CT scans are medically necessary. The Plan denied your request. The Plan says the CT scans are not medically necessary. The enrollee has not had a chest x-ray or picture study using sound waves that showed a need for further imaging or failed to find the source of the enrollee's problem.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of chest with contrast (71260) and a CT scan of abdomen and pelvis with contrast (74177). Our reviewer says that the requested CT scans are not medically reasonable or necessary. Our physician reviewer found that the review indicates that the requested studies do not meet National Comprehensive Cancer Network (NCCN) guidelines.
Based on NCCN Guidelines for Prostate Cancer (Version 2.2020) and NCD for Computed Tomography (220.1) these denials are upheld. The NCD states that a CT should be "medically appropriate considering the patient's symptoms and preliminary diagnosis." The requested scans are not supported by evidence-based guidelines, nor is there evidence that the requested studies are clinically indicated prior to local lymph node biopsy. The review has determined that the requested CT Scans are 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 a CT scan of chest with contrast (71260) and a CT scan of abdomen and pelvis with contrast (74177) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of chest with contrast (71260) and CT scan of abdomen and pelvis with contrast (74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) received March 4, 2021.
You asked the Plan to pay for the surgical placement of implant body: endosteal implant. You say that you had teeth pulled due to an infection, and the implant would have been covered last year but was put off to allow time for healing. The Plan denied your request. The Plan says the requested service is not covered under your 2021 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 surgical placement of implant body: endosteal implant (D6010) received March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH care 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 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 that the enrollee is a 74-year-old female who was admitted to the intensive care unit for breathing problems from a COVID-19 pneumonia requiring intubation and mechanical ventilatory support. 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 she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve a walk-in bathtub. You say that you have excruciating pain day in and day out. You state you have been in hot jets for an extended time and it has given you good relief. The Plan denied your request. The Plan says a walk-in bathtub is not primarily and customarily used to serve a medical purpose and is generally useful in the absence of illness or injury.
The Plan must follow Medicare rules. Medicare rules say that a walk-in tub is not covered because they are not primarily medical in nature. While a a walk-in tub may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Advair Diskus.
You asked the Plan to pre-approve Advair Diskus. 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-approve Advair Diskus.
Benefits for Advair Diskus may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections.
You asked the Plan to pre-approve sacroiliac joint injections. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 sacroiliac joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of physical exam findings or imaging that support the diagnosis of sacro-ilitis. There is no documentation of conservative therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections.