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

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you feel discriminated by this denial for having urine incompetence. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transcranial magnetic stimulation (90867,
90868 and 90869).
You asked the Plan to pre-approve additional transcranial magnetic stimulation. You say that this is medically
necessary. The Plan denied your request. The Plan says criteria for additional transcranial magnetic stimulation
have not been met.
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation re-treatment services
are subject to the criteria listed 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 additional transcranial magnetic
stimulation. Our reviewer says that the requested services are not medically reasonable and necessary. Our
physician reviewer found that the enrollee is a 65-year-old woman who has treatment resistant depression. The
patient had received a trial of transcranial magnetic stimulation back in June 2017. The degree and duration of
the anti-depressant effect is not quantified in the medical records. In this case, there is insufficient
documentation of the effectiveness of the prior treatment to proceed with another round of therapy as required
by the LCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional transcranial magnetic stimulation have not been met. Therefore, we
decided that the Plan does not have to pre-approve additional transcranial magnetic stimulation (90867, 90868
and 90869).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on December 19, 2020.

You asked the Plan to pay for the subsequent hospital care. You say that the enrollee was in hospice from November 24, 2020, to December 17, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 17, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and treatment with a headache specialist to
be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON headache specialist services. You say that you have been seeking
treatment for your chronic, severe headaches for some time and have had issues getting access to the care you
require. You state that your Primary Care physician (PCP) referred you to a pain management specialist who
does not treat headaches at all. You were able to find this OON doctor who is able to provide this care, whom
you trust. The Plan denied your request. The Plan says there are network providers available who can provide
the care you require.
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
consultation and treatment with a headache specialist to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
You asked the Plan to pre-approve the dentures. You say that new dentures are necessary. The Plan denied your request. The Plan says dentures may only be covered once every 60 months. The Plan paid for dentures for you in June of 2018, which is less than 60 months before the date of this decision.
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 can cover dentures once every 60 months. Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 19, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 19, 2019,

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 19, 2019,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01402 provided on October 22,
2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

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 01402 is not supported in the medical record. Specifically, the documentation shows
that 140 units of this service were billed. The documentation submitted does not support the units billed. Based
on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01402 provided on
October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of distal radial fracture coded 25600 provided on December 21, 2020.
You asked the Plan to pay for the closed treatment of distal radial fracture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 25600 is closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation.
We find that CPT code 25600 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the closed treatment of distal radial fracture have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of distal radial fracture coded 25600 provided on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5212).

You asked the Plan to pre-approve a lower partial denture. You say that your current lower partial did not fit, it
accidentally got thrown away, and you need a replacement. The Plan denied your request. The Plan says the
service is a covered benefit, but you have exceeded the frequency limit of one every 5 years.

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 lower partial denture have not been met. Specifically, the record shows that you had exceeded the
frequency limit prior to this service on August 26, 2019. Therefore, we decided that the Plan does not have to
pre-approve a lower partial denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are currently using a wooden board to shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the labial veneer (porcelain laminate) (D2962) received November 30, 2020.

You asked the Plan to pay for the labial veneer (porcelain laminate) (D2962). You say that the provider led you to believe that the requested service was a covered benefit, therefore you should not have to pay. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the labial veneer (porcelain laminate) (D2962) received November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer.

You asked the Plan to pre-approve Superion interspinous spacer. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were being treated for spinal stenosis, lumbar region with neurogenic claudication. You presented with low back pain and right hip pain. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in enrollees with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. You have multiple degrees of spinal
stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level of implantation L3/4). Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam image capture (D0367).
You asked the Plan to pre-approve the cone beam image capture. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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 pre-approve a cone beam image capture (D0367).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on October 5, 2020.
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 81455 is targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed.
We find that CPT code 81455 is not supported in the medical record. Specifically, the services provided should be billed with code 81479. In addition, the appropriate DEX-Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on October 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on December 22, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 17, 2020. The service in question was provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 3 and 5.

You asked the Plan to pre-approve the dental services. You say that the crowns for teeth # 3 and 5 are needed in order to replace tooth # 4 with a pontic. You say that this will also improve mastication, as the enrollee is having difficulty chewing due to missing this tooth.The Plan denied your request. The Plan says the crowns for teeth # 3 and 5 are not medically necessary. The Plan says that there is no pathologic destruction to the teeth that supports the medical necessity for crowns.

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 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 to pre-approve the dental services. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found the provided records do not demonstrate pathologic destruction to the tooth # 3 or # 5 by caries, or trauma, and does not involve four or more surfaces and two or more cusps. Therefore, the reviewer found that the crowns for teeth # 3 and 5 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 the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 3 and 5.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron Emission Tomography and Computed Tomography (PET-CT) scan of whole body (78816).

You asked the Plan to pre-approve PET-CT scan of whole body. You say that this service is medically necessary.The Plan denied your request. The Plan says the criteria for this service have not been met at this time.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET-CT scan of whole body. Our reviewer says that the requested imaging service is not medically necessary and reasonable. Our physician reviewer found a PET scan is requested for this patient with what is described as autonomic dysreflexia with increase in episodes. Blood work is not suggestive of carcinoid syndrome. A rationale for PET scan is not given and not clear from provided medical records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET-CT scan of whole body have not been met.Therefore, we decided that the Plan does not have to pre-approve Positron Emission Tomography and Computed Tomography (PET-CT) scan of whole body (78816).