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

We decided that the Plan does not have to pre-approve an excision of benign lesion (D7410), arthrocentesis (D7870), and intravenous moderate (conscious) sedation/analgesia (D9239).
You asked the Plan to pre-approve the excision of benign lesion, arthrocentesis, and intravenous moderate (conscious) sedation/analgesia. You say that the enrollee was referred to your office for extractions and biopsies. You also say that the enrollee is in pain and is very nervous for the treatment. The Plan denied your request. The Plan says these services are 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 pre-approve an excision of benign lesion (D7410), arthrocentesis (D7870), and intravenous moderate (conscious) sedation/analgesia (D9239).
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 prescribed for obstruction of bile duct. 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 pre-approve a pontic (D6240) for tooth #29, retainer crown (D6750) 
for tooth #28, and core buildups, including any pins when required (D2950) for tooth #'s 28 and 30. 
 
You asked the Plan to pre-approve the pontic, retainer crown, and core buildups. You say that you would like 
to save as many of your own teeth as possible. You also say that your bite is off, and you cannot chew. The 
Plan denied your request. The Plan says your plan does not cover these procedures. 
 
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 
pontic (D6240) for tooth #29, retainer crown (D6750) for tooth #28, and core buildups, including any pins 
when required (D2950) for tooth #'s 28 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan has to pre-approve a lap sleeve gastrectomy procedure.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that bariatric surgery is covered when specific criteria
are met.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the records show that you have
hypertension, gastroesophageal reflux disease (GERD), asthma, and degenerative joint disease. You have
completed a multidisciplinary evaluation, including dietary, medical, cardiac, and psychological evaluations.
You have failed past conservative efforts at weight loss. Your body mass index (BMI) is 44 kg/m2. You meet
the criteria for coverage and the requested procedure is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to preapprove
a lap sleeve gastrectomy procedure.
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: Imaging
Decision: Favorable

We decided that the Plan has to pay for radiology services (CPT 72128) provided to the enrollee on March 22,
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 that there is no additional documentation supporting an additional study which was billed and
remains denied.
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 72128 is "Computed tomography, thoracic spine."
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 services. Our reviewers says that the
services at issue in this case were supported by the medical records. Our physician reviewer found a review of
the records show a CT of the thoracic spine. CPT 72128 was done on 3/22/20 with the technique described as
reconstruction of the images from CT of the chest and abdomen together with focused axial reconstruction of
the thoracic spine. As such the documentation shows a CT of the thoracic spine was indeed done based upon
reconstruction of images from the Chest CT and additional axial imaging of the thoracic spine.
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 pay for
radiology services (CPT 72128) provided to the enrollee on March 22, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 17, 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 procedure code 00830 is not supported.
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 00830 is Anesthesia for hernia repairs in lower abdomen; not otherwise specified. We find that CPT code 00830 is not supported in the medical record. Specifically, there is no documentation of an anesthesia procedure for hernia repairs in the lower abdomen.
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 services rendered on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the outpatient surgery services provided to the enrollee on December 1, 2020.
You asked the Plan to adjust the copayment. You say that the copayment should be $40. The Plan denied your request. The Plan says the services processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for surgery services provided at an outpatient hospital facility. Review of the file shows that the enrollee was provided outpatient hospital services on December 1, 2020. Per the enrollee's contract with the Plan, there is a $350 copayment for outpatient surgery. This cost sharing is a contractual obligation that the enrollee agreed to pay upon enrolling in the Plan.
However, the Medicare allowed amount for these services was $173.07. Given that the allowed amount was less than the $350 copayment, the enrollee has been asked to pay $173.03 for these services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. Therefore, we decided that the Plan does not have to adjust the copayment for the outpatient surgery services provided to the enrollee on December 1, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 review has determined that the complexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation
facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission 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 documentation does not support the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require at least 3 hours per day/5 days a week, or 15 hours over 7 consecutive days, of therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 2, 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 procedure codes Q4186, 15275, and 29580 are not supported.
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 Q4186 is Epifix, per square centimeter. The definition of
code 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound
surface area. The definition of code 29580 is strapping; Unna boot.
We find that CPT codes Q4186, 15275, and 29580 are not supported in the medical record. Specifically, there
is no documentation of Epifix for the billed date of service to support code Q4186. There is no documentation
of application of a skin graft substitute for the billed date of service to support code 15275. There is no
documentation of strapping of an Unna boot for the billed date of service to support code 29580. 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 surgical services rendered on 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 review has determined that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
There is not a reasonable expectation that this enrollee 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluid Flow injection (Q4206) provided on March 16, 2021.
You asked the Plan to pre-approve a Fluid Flow injection. You say that this was medically necessary. The Plan denied your request. The Plan says this is experimental.
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 Fluid Flow injection. Our reviewer
says that the service at issue is not considered medically reasonable and necessary in this case. Our physician
reviewer found this type of treatment does not currently have sufficient high quality evidence to support its use
in this particular clinical scenario.
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 Fluid Flow injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Fluid Flow injection (Q4206) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental gingival irrigation (code D4921) provided on February 23, 2021.
You asked the Plan to pay for gingival irrigation. You say that you were not informed that gingival irrigation was not covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by the Plan's dental 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 dental gingival irrigation (code D4921) provided on February 23, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission.
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 that the admission 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 these services. Our reviewer says that the admission is medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 9, 2021 with altered mental status, a urinary tract infection, and excoriations. The records show that the enrollee has not reached her maximum level of function. She has skilled therapy needs and requires skilled therapy on a daily basis. As a practical matter, the enrollee requires the necessary services on an inpatient basis at the SNF 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 these services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission.
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 lab services (87798, 87486, 87581) provided May 20, 2020.
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 documentation does not support the services billed.
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 codes 87798, 87486, & 87581 are not supported in the medical record. Specifically, the place
of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11,
office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87798, 87486, 87581)
provided May 20, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing needs in an inpatient setting.
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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a modified independent assist level with functional mobility. He required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.